Policy Certificate - Group Personal Accident

ICICI Lombard Group Personal Accident Policy no. POLMBKBA82EFIJB dated 19 Feb 2019 10:22 PM has been
issued at Mumbai, by ICICI Lombard General Insurance Company Limited to the Policyholder Giridharan Venkatraman
, as specified in the policy and is governed by, and is subject to, the terms, conditions & exclusions therein contained or
otherwise expressed in the said policy, but not exceeding the sum insured as specified in Part I of the schedule to the
said policy.

This certificate, issued under the signature of an authorized signatory of the Company represents the availability of
benefit to the insured named below, Customers of One Mobikwik Systems Private Limited subject to the terms,
conditions and exclusions contained or otherwise expressed in the said Policy to the extent of sum insured mentioned
as maximum liability, but not exceeding the Sum Insured as specified below.

Policy No. POLMBKBA82EFIJB

Policy Tenure(in months) 12

From: 19 Feb 2019 10:22 To: 18 Feb 2020 10:22

Period of Insurance
PM PM

Insured Name Giridharan Venkatraman

Contact No. 9944637210

Email ID giridharanr550@gmail.com

Policy Issuing Office Prabhadevi

PREAMBLE
ICICI Lombard General Insurance Company Limited ("the Company"), having received a Proposal and the premium
from the Policy holder named in the Schedule referred to herein below, and the said Proposal and Declaration together
with any statement, report or other document leading to the issue of this Policy and referred to therein having been
accepted and agreed to by the Company and the Policy holder as the basis of this contract do, by this Policy agree, in
consideration of and subject to the due receipt of the subsequent premiums, as set out in the Schedule with all its Parts,
and further, subject to the terms and conditions contained in this Policy, as set out in the Schedule with all its Parts that
on proof to the satisfaction of the Company of the compensation having become payable as set out in Part I of the
Schedule to the title of the said person or persons claiming payment or upon the happening of an event upon which one
or more benefits become payable under this Policy, the Sum Insured/ appropriate benefit amount will be paid by the
Company.
Insured Details

Relation
Date Relationship of
Sr Risk Beneficiary /
Name in Full of Gender Occupation with Nominee
No: Category Nominee
Birth Proposer with the
Insured

Personal
Giridharan 9/9 G.
#1 Male Accident Father
Venkatraman /1989 Venkatraman
Insurance

Benefit & Extension Table

Benefit Cover Benefit Amount Sum Insured (Rs.)

1 Death due to Accident 100% of Sum Insured

Rs.100,000.00
2 Permanent Total Disability 100% of Sum Insured

Premium Details

Basic Premium 20.0

GST (As Applicable) 0

Total Amount 20.0

Agent / Broker Details

Agent Name NA Agent Code NA Agent contact No. NA

Important Notes:

1. Insurance cover will start only on receipt of complete premium by ICICI Lombard General Insurance Company Limited
2. Insurance cover is subject to the terms and conditions mentioned in the Policy wordings provided to you with this
Certificate
3. The above covers would not be applicable for persons occupied in underground mines, explosives and electrical
installations on high tension lines
4. Major exclusions: Intentional self-injury, suicide or attempted suicide whilst under the influence of intoxicating liquor or
drugs, Any loss arising from an act made in breach of law with or without criminal intent.
5. The claimant can contact us at Toll Free Number 1800-2-666 or Email us at customersupport@icicilombard.com for
lodging the claim.
6. Claim Notification address: IL Health Care,Secure Mind Claims,ICICI LOMBARD HEALTHCARE ICICI BANK TOWER,
PLOT NO.12FINANCIAL DISTRICT,NANAKRAM GUDA,GACHIBOWLI,HYDERABAD
 For ICICI Lombard General
Insurance Company ltd.
Authorised Signatory
Important: Insurance benefit shall become voidable at the option of the company, in
the event of any untrue or incorrect statement, misrepresentation non-description of
any material particular in the proposal form/ personal statement, declaration and
connected documents, or any material information has been withheld by beneficiary or
anyone acting on beneficiaryâs behalf to obtain insurance benefit. Please note that any
claims arising out of pre-existing illness/ injury/ symptoms is excluded from the scope
of this policy subject to applicable terms and conditions. Refer to policy wordings for
the terms and conditions. All disputes are subject to the jurisdiction of Mumbai High
Court only. For claims, please call us at our toll free no. 1800 2666 or e-mail to us at
ihealthcare@icicilombard.com or write to us at ICICI Lombard GIC, ICICI Bank Tower,
Plot no-12, Financial district Nanakramguda, Gachibowli, Hyderabad, Andhra Pradesh
500032

This policy has been issued based on the details furnished by the policyholder. Please review the details furnished in the
policy certificate and confirm that same are in order. In case of any discrepancy/ variation, you are requested to call us
immediately at our toll free no. 1800 2666 or write to us at customersupport@icicilombard.com. In the absence of any
communication from you within the period of 15 days of receipt of this document, the policy would be deemed to be in order
and issued as per your proposal. All refunds and claim payment will be done through NEFT only. In case of addition of
member/ increase in sum insured, fresh waiting period will be applicable to new member/ increased sum insured. This policy
certificate is to be read with the policy wordings, as one contract or any word or expression to which a specific meaning has
been attached in any part of this policy shall bear the same meaning wherever it may appear.

Product UIN: ICIPAGP03004V040203

CIN: L67200MH2000PLC129408